NPIMap

Organization Active NPI

Greene Memorial Hospital Inc

Doing business as Kettering Health Primary Care, A Service of Kettering Health Greene Me

  • Rural Health Clinic/Center
  • Cedarville, OH
National Provider Identifier
1073948774
Registry record updated Nov 25, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
GREENE MEMORIAL HOSPITAL INC
Doing business as
Kettering Health Primary Care, A Service of Kettering Health Greene Me
Practice address
29 Kyle Dr
Cedarville, OH 45314-9580
Phone
(937) 766-2611
Fax
(937) 766-5558
NPI assigned
Sep 12, 2013
Last updated
Nov 25, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
GREENE MEMORIAL HOSPITAL INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 25, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy Ko
Title
Network Cfo
Phone
(937) 395-8522

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

29 Kyle Dr
Cedarville, OH 45314-9580

Mailing address

2110 Leiter Rd
Miamisburg, OH 45342-3598

Other names 1

  • Kettering Health Primary Care, A Service of Kettering Health Greene Me Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150331000777 OH Part A Provider - Rural Health Clinic 3971406539 Practice locations: Cedarville, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073948774. Details of each certification follow.

Rural health clinic certification: CCN 363400

Legal name
GREENE MEMORIAL HOSPITAL INC
Doing business as
KETTERING HEALTH PRIMARY CARE, A SERVICE OF KETTERING HEALTH GREENE ME
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 25, 2015
Last certification
Jun 25, 2015
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Dec 29, 1971 in OH
Enrollment address
29 Kyle Dr
Cedarville, OH 45314-9580
Related CCNs
360026

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Part of
Greene Memorial Hospital

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Roy Chew Individual Corporate DirectorBoard Member May 1, 2022
Delthony Gordon Individual Corporate DirectorBoard Member May 1, 2021
Thomas Peebles Individual Corporate DirectorBoard Member Jan 1, 2020
Celeste Blyden Individual Corporate DirectorBoard Vice Chair Feb 1, 2023
Philip Parker Individual Corporate DirectorBoard Member Jan 1, 2020
Michael Mewhirter Individual Corporate OfficerInterim Ceo, Kettering Health Nov 11, 2022
Corporate DirectorBoard Chair Nov 11, 2022
Daniel Tryon Individual Corporate DirectorSecretary Nov 11, 2021
W-2 Managing EmployeePresident Nov 11, 2021
Troy Alan Tyner Individual Corporate DirectorBoard Member May 1, 2021
Timothy Y Ko Individual Corporate OfficerInterim Cfo, Kettering Health Nov 18, 2022
Corporate DirectorTreasurer Oct 1, 2022
Amol Soin Individual Corporate DirectorBoard Member May 1, 2021
Robert Smith Individual Corporate DirectorBoard Member May 1, 2022
Richard J Manchur Individual Corporate OfficerPresident May 1, 2020
Corporate DirectorBoard Member May 1, 2021
Kettering Adventist Healthcare Organization, Miamisburg, OH Corporation, Non-profit Operational/Managerial Control Jul 31, 2009 100%
Cherish J Prutzman Individual Corporate DirectorBoard Member May 1, 2020

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 11

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1378944000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1073948774",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2110 LEITER RD",
            "city": "MIAMISBURG",
            "state": "OH",
            "postal_code": "453423598"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "29 KYLE DR",
            "city": "CEDARVILLE",
            "state": "OH",
            "postal_code": "453149580",
            "telephone_number": "937-766-2611",
            "fax_number": "937-766-5558"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREENE MEMORIAL HOSPITAL INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GREENE MEMORIAL HOSPITAL INC",
        "enumeration_date": "2013-09-12",
        "last_updated": "2024-11-25",
        "certification_date": "2024-11-25",
        "status": "A",
        "authorized_official_last_name": "KO",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_title_or_position": "NETWORK CFO",
        "authorized_official_telephone_number": "937-395-8522"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kettering Health Primary Care, A Service of Kettering Health Greene Me",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cedarville, OH

Sources for this page

Verify at the official NPI Registry.